Youth Group Registration Form

Thank you for your interest in Alive's Youth Group. Please complete the following information to register.

Parent/Guardian Information

Legal Parent/Guardian
First Name *

Last Name *

Your relationship to the child
you are registering? *

Phone Number *

E-mail Address *

Street Address *

Address Line 2

City *

Zip Code *

County *

Youth Information

Please fill out this section for each child you are registering.

Child's
First Name *

Last Name *

Preferred Name

Date of Birth * +

Age *

Race (collected for grant funding purposes only) *

If Other, Please Identify:

Gender Identity *

Current Grade *

School Child Presently Attends *

We will let you know on weekly basis what dinner we are providing. If it is a meal your child is not able to eat, we welcome you to send your child with an alternative option. So we are aware, please note any allergies or sensitivities below:

Do you have another child you would like to register? *

Yes

No

First Name *

Last Name *

Preferred Name

Date of Birth * +

Age *

Race or Ethnicity (collected for grant funding purposes only) *

If Other, Please Identify:

Gender Identity *

Current Grade *

School Child Presently Attends *

We will let you know on weekly basis what dinner we are providing. If it is a meal your child is not able to eat, we welcome you to send your child with an alternative option. So we are aware, please note any allergies or sensitivities below:

Do you have another child you would like to register? *

Yes

No

First Name *

Last Name *

Preferred Name

Date of Birth * +

Age *

Race or Ethnicity (collected for grant funding purposes only) *

If Other, Please Identify:

Gender Identity *

Current Grade *

School Child Presently Attends? *

We will let you know on weekly basis what dinner we are providing. If it is a meal your child is not able to eat, we welcome you to send your child with an alternative option. So we are aware, please note any allergies or sensitivities below:

Do you have another child you would like to register? *

Yes

No

First Name *

Last Name *

Date of Birth * +

Age *

Race or Ethnicity (collected for grant funding purposes) *

If Other, Please Identify:

Gender Identity *

Current Grade *

School Child Presently Attends? *

We will let you know on weekly basis what dinner we are providing. If it is a meal your child is not able to eat, we welcome you to send your child with an alternative option. So we are aware, please note any allergies or sensitivities below:

Loss Information

The following questions are about the loss your child has experienced.

First and Last Name of Deceased *

Relationship to Child *

What did they call the person who died (i.e. Nanna, Uncle, Mike, Papa) *

Was the deceased a patient of Alive Hospice? *

Yes

No

Date of Death * +

Please include a brief explanation about the cause of death. *

Any additional information you would like to include: *

Important Notice

Regular attendance is important as it allows us to best prepare each evening and encourages group bonds. Let us know if you have any preplanned commitments on the following dates that will cause your child to miss youth group. (Notice: We will not be meeting the week of Tuesday, 3/14) *

Our team will reach out to if there is an inability to attend the first meeting to discuss details further.

Please sign below acknowledging that you are aware of the commitment and dates of group *

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